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 Formulary Chapter 4: Central nervous system - Full Chapter
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Link   Choice and Medication: Mental Health – information for patients
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04.10  Expand sub section  Drugs used in substance dependence
 link Link    Further Information: Smoking Cessation
 link Link    NHS STOP Smoking Services. Service Monitoring & Guidance 2011/12
 link Link    NICE PHG1: Brief interventions and referral for smoking cessation.
 link Link    NICE PHG10: Smoking Cessation Services
 link Link    NICE TA123: Smoking cessation - varenicline
04.10  Expand sub section  Alcohol dependence
04.10  Expand sub section  Cigarette smoking
 note 

Smoking Cessation- Prescribing Points

  • Smoking remains the biggest preventable cause of ill-health and premature death and the biggest driver of health inequalities particularly cancer, coronary heart disease and respiratory disease.
  • All patients, wherever they are, who wish to quit smoking can be referred to the Leicestershire NHS STOP! Smoking Service.  
  • Behavioural therapy should always be provided alongside pharmacotherapy either as direct provision or by the STOP! Smoking Service, as it significantly increases the chance of quitting successfully.
  • Most smokers need to make multiple attempts to quite before achieving long-term success.Treatment should be available for more than one episode providing patients are adequately motivated to attempt to stop smoking again.
  • Appropriate governance mechanisms should be in place to provide comprehensive advice on treatment, monitor use, agree quit dates and a plan of ongoing support at the end of treatment.
  • Smoking is not allowed on secondary care premises.
  • Smoking cessation medications should be chosen according to patient specific requirements. Consider patient preference, motivation, cigarettes smoked per day, the time to the first cigarette of the day, desired speed of nicotine delivery, ability to adjust and titrate nicotine dose, tolerance for side effects, interactions and ease of use.  In more dependent smokers a combination of short and long acting NRT should be considered to relieve craving.
  • NRT can be prescribed for in-patients over the age of 12 years for the short term management of craving and withdrawal symptoms. 
  • All in-patients who smoke should be encouraged to agree to referral to STOP! Smoking Service. In patients unwilling to be referred for smoking cessation NRT can be offered for temporary abstinence or to allow a reduction in smoking in line with NICE PH45 Tobacco: harm reduction approaches to smoking.
  • Smoking cessation can affect levels of medication and dose adjustment may be necessary e.g. clozapine.  Further information and advice can be obtained from the Medicines Information Service on 0116 258 6491.
  • The risks and benefits of NRT should be discussed with pregnant women who smoke, particularly those who do not wish to accept the offer of help from the NHS Stop Smoking Service. If a pregnant woman is unable to give up without pharmacological therapy the risks of NRT are lower than those of smoking tobacco  Pregnant women using nicotine patches should be advised to remove them before going to bed (use for 16 hours per day).
Nicotine Replacement Therapy
View adult BNF View SPC online  Track Changes 		Formulary
Green 		Long-Acting:
≥ 10 cigarettes per day – NiQuitin Patch 21mg/24 hours applied daily
< 10 cigarettes per day – NiQuitin Patch 14mg/24 hours applied daily
In pregnant women recommend removing for 8 hours over night

Short-Acting:
  • NiQuitin Mini Lozenge 4mg
    One lozenge dissolved in the mouth whenever there is an urge to smoke (maximum 15 lozenges per 24 hours)
  • NiQuitin Strips 2.5mg Oral Film
    One strip to be dissolved in the mouth every 1-2 hours when there is an urge to smoke (maximum 15 strips per 24 hours)
  • Nicorette Inhalator 15mg
    Use whenever there is an urge to smoke (maximum 6 cartridges per day equivalent to approximately 48 x 5 minute sessions)
    Caution may be restricted in the prison environment.
  • Nicorette Quickmist 1mg/spray Mouthspray
    Use 1-2 sprays whenever there is an urge to smoke (maximum 4 sprays per hour and 64 sprays per 24 hours)

    • Full range available through the STOP! Clinics and primary care prescribers. Also available from community pharmacists under an enhanced service agreement .
     
       
    Bupropion Hydrochloride
    View adult BNF View SPC online  Track Changes     		Formulary
    Green     		Only available in primary care and STOP clinics
    The mode of action of bupropion in smoking cessation is unclear but may involve an effect on noradrenaline and dopamine neurotransmission. It should not be used in patients with a history of seizures, acute alcohol or benzodiazepine withdrawal, hepatic cirrhosis, CNS tumour, eating disorders or bipolar disorder.
     
       
    Varenicline
    View adult BNF View SPC online  Track Changes     		Formulary
    Green     		Only available in primary care and STOP clinics.
    Varenicline is a selective nicotine receptor partial antagonist and is currently extensively monitored by the MHRA for suicidal behaviour. If suicidal thoughts, depressed mood or agitiation develop, medical advice should be sought promptly and treatment discontinued. Patients with a history of psychiatric illness should not be prescribed varenicline.
     
       
    04.10  Expand sub section  Opioid dependence
    04.10.01  Expand sub section  Alcohol dependence to top
    04.10.02  Expand sub section  Nicotine dependence
    04.10.03  Expand sub section  Opioid dependence
    04.10.03  Expand sub section  Opioid substitution therapy
    04.10.03  Expand sub section  Adjunctive therapy and symptomatic treatment
    04.10.03  Expand sub section  Opioid-receptor antagonists to top
     ....
    Key
    note Notes
    Section Title Section Title (top level)
    Section Title Section Title (sub level)
    First Choice Item First Choice item
    Non Formulary Item Non Formulary section
    Restricted Drug
    Restricted Drug
    Unlicensed Drug
    Unlicensed
    Track Changes
    		 Display tracking information
    click to search medicines.org.uk
    		 Link to adult BNF
    click to search medicines.org.uk
    		 Link to children's BNF
    click to search medicines.org.uk
    		 Link to SPCs
    SMC
    		 Scottish Medicines Consortium
    High Cost Medicine
    		 High Cost Medicine
    Cancer Drugs Fund
    		 Cancer Drugs Fund
    NHSE
    		 NHS England
    Homecare
    		 Homecare
    CCG
    		 CCG

    Traffic Light Status Information

    Status Description

    Black

    		 Drugs not recommended for use in the Leicestershire Health Community because of lack of evidence of clinical effectiveness, cost prioritization or concerns over safety. All new drugs will be black until they have been through the appropriate approval process - then they will appear as a specific entry   

    Red

    		 Drugs which should be prescribed only by hospital specialists (clinical review by specialist as appropriate and annually as a minimum).  

    Amber SCA

    		 Drugs which would initially be prescribed by a hospital specialist and then by a GP where full agreement to share the care of each specific patient has been reached under a LMSG Shared Care Agreement (SCA). Specific patient monitoring or intervention required.   

    Amber Simple

    		 Drugs suitable to be initiated and prescribed in primary care only after specialist assessment and recommendation. A shared care agreement is not required.  

    Green Conditional

    		 Drugs for which GPs are able to take full responsibility for prescribing and monitoring subject to specified conditions e.g. prescribing in line with agreed LMSG guidance or able to demonstrate suitable competence see comments under individual entries.   

    Green

    		 Drugs for which GPs would normally take full responsibility for prescribing and monitoring. Drugs included in this list have been specifically considered by LMSG.   

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